Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, July 29, 2009

Back to Public Health

What with the Capitol Hill health care reform circus, I feel I've been neglecting our mission here. Let's not forget that for the most part, health care is all about spending too much money too late to partially fix problems that never should have happened in the first place.

Here and there in the corporate media we saw a tiny bit of attention paid to this analysis by Finkelstein and the gang in Health Affairs, which they are kindly allowing you to read, which finds that the increasing prevalence of obesity in the U.S. (from 18.3 percent of the population in 1998 to 25.1 percent in 2006 -- an astonishing, overwhelming disaster) has contributed substantially to rising medical costs. Medical spending on obese people in 2006, they estimate, was $1,429 higher than for people of normal weight. Obesity accounted for 6.5% of all medical spending in 1998, and for 9.1% in 2006.

This report in JAMA (abstract only for you common rifraff) finds, based on a prospective cohort study (which is the very best kind of epidemiological study) that what the authors call "lifestyle" factors can double the risk of heart failure in men -- or rather, specifically, male physicians, which is an odd sort of cohort in many ways but since they presumably get top notch medical care it is a particularly good one for isolating other factors. This is no small matter on a population basis because we are talking about a 21.2% lifetime risk among the guys who don't eat their veggies, smoke, don't exercise, etc. compared with 10.1% among those who do what grandma told them to do. And you really do not want to develop heart failure. (Non-physicians are at higher risk overall, BTW. 21.2% is comparable to the overall risk for the general population.)

Now, compare these extremely urgent, very expensive and deadly public health problems with the absurd amount of attention being paid to swine flu. Why do you think the focus is so strongly in the wrong place?

13 comments:

C. Corax
said...

People don't take kindly to being told, "You're fat!"--hurts ratings. Plus swine flu is contagious, obesity isn't, so it's scarier. Also, we tend to fear the unfamiliar. Obesity is getting more familiar all the time.

Actually, in a sense, obesity is contagious. I'm too lazy right now to dig up the reference, but a social network analysis done a couple of years ago found that obesity actually tends to spread among friends and family. One can think of various reasons why this might be.

Anyway, contagious or not, obesity is a much bigger problem for someone who gets it than swine flu. 99.9% of the time, if you get swine flu, you'll be sick for a week and then you will be all better, and immune forever. Obesity, however, is extremely difficult to cure and can ruin your life.

Obesity is behavioral, and you have an American God-given right to eat whatever you damn well please. Tell the govt not to come between me and my big mac. And I'll have a large side of fries on the side. Thank you very much.

Basically right, Roger, the Holy Grail of a pharmaceutical treatment for obesity is still elusive. The only effective medical treatment for obesity is surgery -- but that's big business these days.

I agree with Robin that there's a glibertarian attitude that's dismissive of obesity as a public health problem -- it's your own fault, personal responsibility, yadda yadda -- but as you know I've made something of a career here debunking that sort of argument. I suppose I'll have to keep at it . . .

I really enjoy reading this blog. I have put together a website on health reform that touches on many of the issues on this site. I would love for any or all of you to visit and both enjoy its content and let me know what you think.

i think obesity is rather complicated -- first because people come in different body types, and secondly because there are hugely conflicting cultural messages.

cervantes nailed one of the nastiest cultural messages -- if you don't fit the mold, it must be because of some moral or disciplinary failure on your part. that is one horrible, destructive approach, and especially for young women, who are the targets of really unhealthy body expectations and criticism -- as well as a million miracle diets and cures.

what kinds of things might make a practical difference? well, talking about health vs. beauty ideals is a start. making healthy food easier and more affordable would be great -- not everyone is in a position to cook everyday from scratch, and it is an economic fact that a bacon double cheeseburger is easier to find and costs less than a lot of other healthier options. the fries are practically free.

teh supersize phenomenon is huge. i don't just mean for fast food; restaurant portions tend to be enormous.

what i really really like is what happens at potlucks [or, with family-style dinners] -- there's a good variety of food, everyone helps themselves and spends a lot of time talking and laughing, and the big worry is dividing up the leftovers. despite the ton of food, nobody eats TOO much -- there is plenty, you serve yourself, and good company etc.

Now that you mention it, the Reveres over at Health Effect did a post about bad journalism, but it also touched on a possible link between obesity and acute respiratory distress syndrome among swine flu patients. Hmm.

I'm curious what you think about a tax on the sale of sweetened beverages. (Sorry if you addressed this elsewhere.)

My take - I think it's regressive. Also, and I realize I'm in a minority here, I think obesity is more of a social problem than an individual problem.

If obesity was an individual problem then you could take an overweight American out of the US and replant him in some places in Africa or China and he would retain his weight problem, if possible. Likewise, you could take a person without a weight problem from China or Africa and replant him here and he would not gain weight. (This last one I have read is not the case, transplants do gain weight when they come here.) So - there are strong social forces acting.

(As to your question, I agree somewhat with roger. Swine flu is tackleable, you can develop a vaccine. Obesity is big.)

former fda commissioner david kessler has a new book out about our food, "the end of overeating," in which he points out that most fast food and much restaurant food is some combo of sugar, fat, and carbs, which produce in the consumers a high which is not habituated. apparently those addicted to the stuff get high just thinking about a big mac. the "sugar" being high fructose corn syrup, which is cheap because of subsidies to corn growers. cheap corn also fuels cattle feed lots, which produce beef with too much fat. cheap corn enables at least 2 bad food trends.

good points, roger. and yet, a plain ear [or 1/2 ear] of corn is healthy. the devil is in the processing. KFC offers corn along with fried everything, but unfortunately, it is overcooked and slathered with something butter-like.

this is off-topic on obesity, but another fast-food concern. so much prepared and fast food is wildly, wildly over-laced with salt.